Healthcare professionals' acceptance of COVID‐19 vaccination for their children: A cross‐sectional study at a tertiary care hospital in Western India

Abstract Background and Aims Establishing a transparent and forthright dialog between healthcare professionals (HCPs) and the public is paramount in promoting the effective acceptance of COVID‐19 vaccination for children. Hence, this study aimed to assess the COVID‐19 vaccine acceptance, knowledge, and perception among HCPs for their children. Methods A cross‐sectional study was conducted among HCPs at a tertiary care teaching hospital in Western India. A structured questionnaire was designed and validated to collect data. Descriptive statistics were used for data analysis. Results The study found that more than 80% of HCPs had good knowledge about COVID‐19 vaccines, and 92.74% of them were willing to accept the vaccine for their children. Doctors were more likely to vaccinate their children, and 73% of HCPs had a favorable attitude toward immunizing their children if a new COVID‐19 vaccine was available. Academic/peer‐reviewed publications were considered the most reliable source of information for COVID‐19 vaccination, followed by government sources. Conclusion This study found that parental vaccine hesitancy was significantly lower among the HCP group. The majority of HCPs were in favor of vaccinating their children against COVID‐19, indicating that they can serve as an effective channel for promoting parental acceptance of COVID‐19 vaccines in the community.


| INTRODUCTION
Vaccine hesitancy has been identified as one of the top 10 threats to global health by the World Health Organization.The vaccines against COVID-19 are the fastest vaccines ever produced for a disease 1 and hence are a matter of concern among the population. 2,3An increasing number of vaccines are being authorized for use in children across the globe. 4On January 3, 2022, the Government of India extended the COVID-19 vaccination for children aged 15-18 years. 5Vaccinating children against COVID-19 protects children from rare but severe cases of COVID-19 infection and reduces the further spread of the virus within the community. 6Despite the low risk of severe illness and mortality from COVID-19 among children, it is notable that the emergence of new variants has been correlated with an augmented prevalence of cases as well as more severe clinical manifestations in younger age groups. 7cording to extant reports, the incidence rate of the Omicron variant among individuals aged less than 5 years was observed to be six to eight times higher in comparison to the Delta variant in the United States. 8,9Consequently, children who have contracted the virus may be susceptible to severe pathological states such as croup and multisystem inflammatory syndrome necessitating rigorous therapeutic interventions, hospitalization, and even admission to intensive care units. 10,11Furthermore, these individuals may endure prolonged symptoms with subsequent deleterious impacts on their overall well-being. 12though rare, it must be acknowledged that COVID-19 fatalities can occur in children.UNICEF reports, as of January 2023, that out of the 367 million COVID-19 cases reported from 105 countries (56% of the total global cases identified by Johns Hopkins University), 21% (75.3 million) of these cases occurred in children and adolescents aged under 20 years. 13r comparative purposes, the population of individuals under 20 years of age makes up 33% (2.1 billion) of the total population (6.5 billion) in the aforementioned 105 countries.Consequently, COVID-19 vaccination remains one of the most effective measures for shielding individuals against infection.[16] Although vaccinating children for COVID-19 is of paramount importance, the issue of vaccine hesitancy among parents represents a significant obstacle.7][18] In India

| Development of the questionnaire
The study utilized a multi-item online questionnaire based on the findings of the literature review.Published COVID-19 vaccine hesitancy questions were adopted and adapted to the study's context from validated sources. 16,18This approach aimed to enhance the data quality and validity and enable easy comparison with other populations.The questionnaire underwent face validity by two experts, after which the questions that received aacceptability of 90%-100% of agreement were retained in the questionnaire.Later on, the questionnaire was sent to three experts to assess and each question required rating on a Likert scale.The questionnaire was also subject to a pilot study on 30 participants after which the Cronbach alpha of each question was calculated and all questions with an alpha rating above 0.70 were included in the final version of the questionnaire.

Highlights
• More than 80% of healthcare professionals (HCPs) had good knowledge about COVID-19 vaccines, and 92.74% of them were willing to accept the vaccine for their children.
• Doctors were more likely to vaccinate their children, and 73% of HCPs had a favorable attitude toward immunizing their children if a new COVID-19 vaccine was available.
• The majority of HCPs considered academic/peerreviewed publications as the most reliable source of information for COVID-19 vaccination, followed by government sources.
• The study found that parental vaccine hesitancy was significantly lower among the HCP group, indicating that they can serve as an effective channel for promoting parental acceptance of COVID-19 vaccines in the community.

| Questions and scale
The questionnaire was prepared in English and it comprises a total of 28 questions: 11 items on demographic details, 6 items on knowledge criteria, 5 items on perception-related criteria, and 6 items on acceptability-related criteria.It consisted of different types of questions, including (Yes/No) questions, open-ended questions, and select all-apply questions.

| Knowledge section
The study evaluated participants' understanding of the COVID-19 vaccine through a set of six questions, with a possible cumulative score ranging from 0 to 10. Bloom's cut-point was utilized to categorize the overall knowledge score as "good" if it was equal to or greater than 80% (8 points). 21

| Perception section
The study measured participants' views on the COVID-19 vaccine through four questions, with a possible cumulative score ranging from 0 to 7. The overall perception level was categorized based on Bloom's cutoff point, with a score of 80% or higher (at least 5.6 points) indicating a positive perception. 21

| Acceptability section
The study evaluated the willingness of participants to receive the COVID-19 vaccine through a set of three questions, with a possible cumulative score ranging from 0 to 4 for each participant.

| Data collection
In this study, data collection was conducted online through Google Forms between May 1, 2022 and June 30, 2022.Recruitment of participants was carried out through various online channels such as WhatsApp and Email, with reminders sent every 2 weeks during the study period to ensure maximum participation.Before participation, all respondents were provided with a participant information sheet (on the first page of Google Form), and given the option to skip any questions or exit the survey at any time.Written informed consent was obtained from all participants, and to ensure anonymity and confidentiality, no personal identifying information was collected.The estimated completion time for the survey was approximately 10 min.To prevent duplication of entries, a oneattempt-per-device setting was implemented.No follow-up was conducted on the participants.No compensation of any sort was provided on completion of the survey.

| Statistical analysis
The collected data was analyzed using GraphPad Prism 9.4.1 for Windows, GraphPad Software, www.graphpad.com.Descriptive statistics were used to summarize the quantitative data, including mean and standard deviation after checking the normality of data using the Kolmogorov test.Qualitative data was presented as absolute (N) and relative (%) frequencies.To determine any association in knowledge groups (good vs. poor), perception (positive vs. negative), and vaccine acceptance (likely vs. unlikely) by demographic characteristics, the chi-square test was applied.Independent sample t test and one-way ANOVA analysis were used to assess any differences in mean knowledge score by demographic characteristics.The statistical significance level was set at p-value < 0.05.

| Demographic information
A total of 441 HCPs participated in this study and were included in the statistical analysis.A total of 441 responses were received from a total maximum pool of 570 HCPs (response rate of 77.4%).

| Acceptability toward COVID-19 vaccines
The majority of the participants (76.4%) trust the existing source of information on COVID-19 vaccination for children.The most common source of information was academic/peer-reviewed journals (70.2%) followed by government sources (51.8%),newspaper/news channels (20.9%), and social media (6.4%) (Figure 2).More than half (53%) of the HCPs were willing to pay for vaccinating their children if the government does not provide vaccination free of charge.In addition, 26% of HCPs have already vaccinated their children, whereas 39% of HCPs will vaccinate their children after few months of vaccine approval.The COVID-19 vaccination acceptance rate among HCPs for their children was found to be 92.74%.
As shown in Table 3, 80% of the HCPs were categorized as having likely vaccine acceptance.As shown in Figure 3 3 shows association in HCPs' COVID-19 vaccine acceptance for their children based on demographics, and there was no significant association found between good knowledge and gender, age group, and profession, respectively.

| DISCUSSION
This study represents one of the few studies conducted in India evaluating HCPs' knowledge, perception, and acceptability of the COVID-19 vaccines for their children.We analyzed COVID-19 vaccine acceptance levels in HCPs who play a pivotal role in vaccine awareness and education in the community, such as doctors, nurses, pharmacists, physiotherapists, and laboratory technicians.In our study, the ratio of male to female participants was found to be nearly equal.The majority of doctors who participated in our study were comprised of males (62.84%, n = 137), whereas nurses were predominantly comprised of females (80.4%, n = 103).
A study conducted by Kadam et al., to assess the HCPs'acceptability of the COVID-19 vaccine for their children found that 90% of the participants (i.e., HCPs) were aware of the vaccine and believed in its usefulness in preventing infection (p = 0.008) and reducing severity (p = 0.009). 22Studies conducted by Lazarus et al. evaluated the COVID-19 vaccine acceptance rates for 23 countries, with India having a 98.3% overall vaccine acceptance and a vaccine hesitancy of 6.3% for children among parents.This compares similarly to our study finding a 92% vaccine acceptance for children. 23The above study also found that India had one of the lowest rates of vaccine hesitancy both overall at 1.7% and also among children at 6.3% among the 23 developing and developed countries.This is lower than the vaccine hesitancy found for general vaccinations for pediatric population which was found to be around 60.2% in a study conducted in tertiary care hospital in Odisha by Banerjee et al. 24 T A B L E 1 Demographic characteristics of healthcare professionals.A study conducted by Miraglia del Giudice et al. on vaccine acceptance and hesitancy among parents of children found the vaccine hesitancy rate to be as high as 26.3%. 25The major factors correlated with the same were less educated, parents who did not get the COVID-19 vaccine, lower concern about the severity of the disease and low perceived risk.As our study included HCPs, the average education level would be expected to be above average and the firsthand experience with COVID-19 and the T A B L E 2 Shows differences in healthcare professionals' knowledge based on demographics toward vaccination against COVID-19 for their children.start of the study. 30In our study, we found that the majority of HCPs were willing to get their children vaccinated with either Covishield (76%, n = 335) or Covaxin (72.1%, n = 318).We found that the majority of HCPs regarded academic/peer-reviewed journals (70.2%, n = 309) as their most reliable source of information, followed by government sources (51.8%,n = 228).This urges the importance of conducting and publishing large-scale studies finding information about vaccine hesitancy and prevalent reasons for the same, so that effective strategies can be developed and put in place to combat the lack of information or misinformation that may be present at large.

| Strength and limitations
An important aspect of our study is that it is one of the few studies in India carried out among HCPs who are parents.We had a small sample size to find clear statistical significance.One of the limitations of our study   Finally, the study did not account for the changing dynamics of the pandemic, including the emergence of new variants and updated guidelines from health authorities which might affect vaccine acceptance over time.

| CONCLUSION
In conclusion, we found that parental vaccine hesitancy was , a study conducted by Padhi et al. indicates that merely 33.5% of Indian parents were willing to vaccinate their children against the disease. 19Parental reservations surrounding their child's COVID-19 vaccination are exacerbated by the deluge of information available on social media platforms concerning the efficacy and safety of the vaccines. 20Therefore, establishing a transparent and forthright dialog between healthcare professionals (HCPs) and the public is paramount in promoting the effective acceptance of COVID-19 vaccination for children.It is therefore of the utmost importance to gain insight into the acceptance of COVID-19 vaccination by HCPs for their children.If HCPs hold reservations and display inadequate confidence in vaccinating their own children against COVID-19, they may encounter significant challenges in fostering trust in the efficacy and safety of COVID-19 vaccines among the wider population, particularly among the parents whom they serve in clinical or community settings.Hence, this study aims to evaluate HCPs' knowledge, perception, and acceptability of COVID-19 vaccination for their children.
HCPs agreed that vaccination against COVID-19 is necessary for children (62.1%, n = 271), whereas 92.1% (n = 407) of HCPs were aware that the COVID-19 vaccine can be given to children (0-14 years).When asked questions regarding the number of vaccine (Covaxin) doses approved for children (12-17 years of age), 75.8% (n = 335) of participants answered two doses.Less than half of HCPs agreed to whether "children have a lower chance of being infected with COVID-19?"Table2showsdifferences in study participants' knowledge based on demographics toward vaccination against COVID-19 and there was significant association between good knowledge and profession, and gender, respectively.The average knowledge score was 6.5 (SD, ±1.98) (range: 0-10).Overall, 81.25% of the participants were categorized as having good knowledge (score > 8).

3 |
Perception toward vaccination against COVID-19Overall, 39.2% of HCPs were confident that COVID-19 vaccines will be safe for children, whereas the majority of HCPs (41.7%) had a neutral viewpoint.Seventy-three percent of HCPs are willing to accept vaccination for their children if a new COVID-19 vaccine becomes available.The average perception score was 3.39 (SD, ±2.55) (range: 0-7).Overall, 54.55% of the participants were categorized as having a positive attitude (score > 5.6).When asked which vaccine they preferred for their child, the majority of HCPs chose to have Covaxin or Covishield followed by Corbevax as shown in Figure1.
, over 90% of HCPs expressed their reasons for vaccine acceptability, of which 52.1% of HCPs accept COVID-19 vaccination for their children due to variety of reasons, including protection against COVID-19 infection in school, protection against COVID-19 infection among family members, prevention from getting COVID-19 infection and its further spread in the community, and for the reduction of severity of infection due to COVID-19.While 7% of HCPs have given reason for rejecting child vaccination against COVID-19 due to uncertainty about the vaccine's safety.Table Abbreviations: %, percentage; N, number of participants.*p value < 0.05 is statistically significant.

F I G U R E 1
Selection of COVID-19 vaccines by healthcare professionals.severity of the disease along with the high risk of transmission would all contribute to a lower vaccine hesitancy rate.The safety and effectiveness of COVID-19 vaccines for younger children is a major concern.About half of the HCPs agreed that vaccination in children is key to stop the pandemic but had a low confidence level due to concerns related to vaccine safety issues in children.The reasons for doubting the effectiveness of COVID-19 vaccines can be attributed to several factors.One possible reason is the lack of information regarding the development and testing of the vaccines.In previous studies individuals have expressed concerns about the transparency of the vaccine development process, preferring vaccines developed in a more open and transparent manner.[26][27][28]Additionally, there are concerns about whether regulatory standards were relaxed and trials rushed due to the unprecedented speed at which COVID-19 vaccines were developed.28,29Despite the low level of confidence regarding the COVID-19 vaccine's safety in children, the majority of HCPs (68.8%, n = 304) themselves were fully vaccinated (booster dose) against COVID-19, either by Covishield or Covaxin, whereas more than one fourth of HCPs (28.5%, n = 126) got a minimum of two doses of COVID-19 vaccine.These findings are similar to a study conducted by Sarkar et al., where 97% of HCPs completed two doses of vaccines before was being a single-center study, underrepresentation of physiotherapists, technicians, and other miscellaneous staff, and overrepresentation of I G U R E 2 Healthcare professionals' source of information related to COVID-19 vaccines.T A B L E 3 Demographic characteristics associated with COVID-19 vaccine acceptance among healthcare professionals for their children.

F I G U R E 3
Distribution of reasons for accepting COVID-19 vaccination by healthcare professionals.doctors.Since our participants are HCPs, if they accept COVID-19 immunization for their children, it will have a beneficial effect on parents in their community, as their views on the acceptability of the COVID-19 vaccine will influence parents' perspectives.The self-report nature of the questionnaire might also introduce social desirability bias, where participants might have reported what they perceived as socially acceptable answers, particularly given the professional standing of the participants as healthcare providers.The study also did not delve into the specifics of different vaccines and their efficacy or safety profiles, which could be a significant factor affecting vaccine acceptance.Furthermore, the study relied on online channels for recruitment and data collection, which might have introduced selection bias.The participants' digital literacy and access to online platforms might have influenced their participation, potentially excluding a segment of the population.The anonymity of responses, while safeguarding confidentiality, also prevented any follow-up or verification of the provided information.
significantly lower in our population of HCPs compared to other research studies.The majority of HCPs replied positively and were in favor of vaccinating their children against COVID-19.The high acceptance of COVID-19 vaccines among HCPs can serve as an effective channel for promoting parental acceptance of COVID-19 vaccines in the community.We found that HCPs regarded academic/peer-reviewed journals as their most reliable source of information for COVID-19 vaccination, followed by government sources.Hence, ensuring the provision of accurate and timely information about COVID-19 vaccines by concerned stakeholders and authorities may enhance public confidence and parental acceptance of the vaccines.